Impact of scapholunate dissociation on human wrist kinematics.

Neither the complex motions of the scapholunate joint, nor the kinematic changes that occur as a result of injury to it, are fully understood. We used electromagnetic tracking within affected bones to evaluate the physiologic motions in the planes of flexion and extension, and of radial and ulnar deviation of human cadaver wrists, before and after complete transection of the scapholunate ligaments. Despite individual variance between each wrist, we were able to establish a pattern in the changes that occurred after scapholunate ligament injury. During the motions examined, the scaphoid showed an increase in translational deviation in almost all motion axes. In contrast, the movement of the lunate seemed to be impaired, especially in radial-ulnar deviation.

Evaluation of facial blood flow using three-dimensional scanning.

The Vectra X3 3-dimensional face scanner allows us to visualise the erythema of superficial layers of skin in addition to its regular scanning functions. The aim of our study was to find out whether changes we provoked in the circulation of the skin would be registered and displayed by the face scanner. We measured the circulation in the skin of the cheeks of 20 volunteers with a face scanner, a laser Doppler device, and a skin pigmentation analyser before and after the application of a nitric oxide cream. The results were compared in terms of grey tones, local concentrations of haemoglobin, and erythema. All methods showed significant changes (p<0.001) before and after application of the cream. The study proved that the Vectra X3 recognises changes in skin circulation and displays them in a simple and evident way.

Necrotizing fasciitis resulting in fatal lung aspergillosis: Uncommon pathogenesis. A case report.

We present a fatal case of Aspergillus-associated lung failure in a patient with necrotizing fasciitis. The cause of the fasciitis was a retroperitoneal perforation of a colon carcinoma. Being already a rare condition, the fasciitis did not manifest as Fournier's gangrene like similar described cases illustrate, but instead travelled along the fasciae and subcutaneous fat tissue cranially into the thoracic cavity, ultimately leading to a disseminated infection of the lungs. The lethal outcome was thus caused by respiratory failure at a time when the primary focus was already successfully treated, contrary to typical cases of necrotizing fasciitis. This case report depicts the importance of acknowledging opportunistic fungal infections in the practice of emergency surgery. Contributing factors, pathogenesis and possible prevention measures are discussed.

Two-component collagen nerve guides support axonal regeneration in the rat peripheral nerve injury model.

Progress in material development has enabled the production of nerve guides that increasingly resemble the characteristics of an autologous nerve graft. In the present study, 20 mm adult rat sciatic nerve defects were bridged with the collagen-based, two-component nerve guide 'Neuromaix', the commercially available NeuraGen® nerve tube or an autologous nerve graft. Neuromaix was able to support structural as well as functional regeneration across this gap. The majority of the axons grew across the scaffold into the distal nerve segment and retrograde tracing confirmed that these axons were of somatosensory and motor origin. Histomorphology revealed that axons regenerating through Neuromaix exhibited reduced myelin sheath thickness, whereas axon diameter and axon density were comparable to those of the autograft. Neuromaix implantation resulted in reinnervation of the gastrocnemius muscle to a level that was not significantly different from that supported by the autograft, as demonstrated by electrophysiology. Our findings show that the use of the Neuromaix scaffold not only allowed axonal regeneration across large nerve gaps, but that the regenerating axons were also able to functionally reinnervate the muscles. These data provide a promising perspective for the first in human application of the materials. Copyright © 2016 John Wiley & Sons, Ltd.

[Registry Research Funding of the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) and Research Funding Report 2015/2016]. / Register Forschungsförderung der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) und Forschungsförderungs-Bericht 2015/2016.

In addition to the impact factor, research funding also plays a central role in evaluating the academic performance and quality of a researcher, a clinic or a surgical specialty. The scope and quality of research in Plastic Surgery are usually very little known, so that even large funding institutions do not get a full view of research funding in our specialty. Therefore, sometimes traditional structures are not adapted to new needs by the developing younger surgical fields. In peer review sometimes peers are not chosen from the same surgical specialty, but from a different surgical fields being peers in large field of surgery. By this a bias can easily be generated which would not be advantageous for subspecialties such Plastic Surgery. The goal of this paper is to establish an overview in the form of a registry of the German Society of Plastic Reconstructive and Aesthetic Surgeons (DGPRÄC) in order to make the joint academic achievements more visible in the future. At the same time, a research funding report is to be published for the years 2015 and 2016.

[Current Perceptions of Lipofilling on the Basis of the New Guideline on "Autologous Fat Grafting"]. / Aktuelle Erkenntnisse zur Eigenfett Transplantation anhand der neuen Leitlinie "Autologe Fetttransplantation".

Introduction: Autologous fat transfer has recently become an increasingly popular surgical procedure and comprises harvesting, processing and transplantation of adipose tissue, as well as professional follow-up care. This method, as a surgical procedure, can be utilised for trauma-, disease- or age-related soft tissue volume deficits and soft tissue augmentation. As usage is increasing, but the variables of fat harvest, specific indications and fashion of fat transfer are poorly defined, there is a great demand for development of a guideline in the field of reconstructive and aesthetic surgery. Methods: All relevant points were discussed within the scope of a consensus conference including a nominal group process of all societies involved in the procedure and ratified with a strong consensus (>95%). Literature from the standard medical databases over the last 10 years was retrieved, studied and specific guidelines were concluded. Results: Consensus was achieved among all professionals involved on the following points: 1. definition 2. indication/contraindication, 3. preoperative measures 4. donor sites 5. techniques of processing 6. transplantation 7. follow-up care 8. storage 9. efficacy 10. documentation 11. evaluation of patient safety. Conclusion: Definite indications and professional expertise are paramount for autologous fat tissue transfer. Successful transfers are based on the use of correct methods as well as specific instruments and materials. Autologous adipose tissue transplantation is considered to be a safe procedure in reconstructive and aesthetic surgery, due to the low rate of postoperative complications and sequelae.

Early Functional Treatment and Modern Cast Making for Indications in Hand Surgery.

Cast treatment can serve both as a nonsurgical treatment option and as a means for providing postoperative protection. However, with the duration of immobilization intervals, the benefits of cast treatment, especially in hand surgery, are at risk of being outweighed by undesired drawbacks such as joint stiffening and contracture formation. In order to minimize potential complications commonly associated with cast treatment, efforts to further improve cast making must attempt to reconcile two conflicting objectives: (1) to achieve stability and rigidity at the site of injury (e.g., fracture retention) and (2) to allow free range of joint movement as early as possible. In addition, in order to assure patient compliance, modern cast treatments should aim to improve wearing-comfort of the cast. This paper describes modern cast designs for four common types hand injuries, with sample cases highlighting the clinical outcome of each treatment.

[Research Assessment in Plastic and Reconstructive Surgery on a National Level: A 5-Years Systematic Review of Research Activity in German University Hospitals]. / Eine Analyse der Forschungsaktivität universitärer Kliniken für Plastische Chirurgie im nationalen Vergleich: Eine systematische 5-Jahres Evaluation der Forschungsaktivität in Deutschland.

BACKGROUND: In plastic surgery, a broad spectrum of research activity has been performed over the past decade. However, compared with other medical fields, there seems to be a lack of central coordination in the individual research areas. Also no comprehensive, periodical assessment has been undertaken to date. This study aims to provide an overview of German research activity in plastic surgery departments affiliated to medical universities. METHODS: We performed a 5-year interval (01/2010-12/2014) survey of PubMed-listed publications of plastic surgery departments in German university hospitals. For each university (n=11), statistical analyses of the following parameters were performed: distribution of research fields, number of publications, annual cumulative impact sum (IS) and impact factor (IF). RESULTS: For the above-mentioned period, a total of n=904 publications were analysed. Ranking among academic departments was as follows: number of publications: 1. Medizinische Hochschule Hannover 178 (annual average x̅=36/median x͂=34; 2. University Hospital of Erlangen 115 (x̅=23/x͂=23); 3. Bergmannsheil Bochum 90 (x̅=18/x͂=19). The annual impact sum (IS) averaged 33.51 (SD 11.088, p<0.05); separated IS: 1. Medizinische Hochschule Hannover x̅=74.66, x͂=62.22, 2. University Hospital of Erlangen x̅=53.24, x͂=50.84, 3. University Hospital RWTH Aachen x̅=46.12, x͂=44.67. The average impact factor per publication was: 1.98 (SD 0.31, p<0.05); separated IF: 1. University Hospital RWTH Aachen x̅=2.76, x͂=2.79; 2. University Hospital of Erlangen x̅=2.34, x͂=2.46; 3. Medizinische Hochschule Hannover x̅=2.08, x͂=2.05. The analysed publications were distributed as follows: 43% reviews, 20% cell biology/tissue engineering, 10% reconstruction, 27% others (including wound healing, vessel/nerve research, hand surgery, burn, aesthetics, oncology). CONCLUSION: Based on this comprehensive analysis, it seems that a periodical assessment of current research activity would be useful for the future. Data assessments should be started on European and international levels and should also be applied to other surgical and medical disciplines.

Extensive burn injury caused by fundamental electronic cigarette design flaw.

Currently, electronic cigarette (EC) devices are widely used as an alternative to conventional smoking. The underlying technical principle is an electric coil-based vaporizer unit, which vaporizes various solutions for inhalation purposes with a rechargeable lithium battery unit as power source. We report a case of extensive burn injury resulting from the thermal explosion of a battery unit within an EC device. Though internal thermal instabilities of lithium ion batteries are a known safety issue, the unique feature here is a pronounced amplification of the extent of burn injury due to an additional scalding burn mechanism that resulted from heating of the liquid reservoir adjacent to the battery. Thus, we demonstrate a relevant design flaw in various EC devices, which in the authors' opinion needs to be addressed both by manufacturers and safety regulations.

Les cigarettes électroniques sont de nos jours très largement utilisées comme alternative au tabagisme. Le principe est la vaporisation aux fins d'inhalation d'un liquide chauffé par une résistance alimentée par une batterie au lithium, rechargeable. Nous rapportons un cas de brûlure étendue causée par l'explosion de la batterie, surchauffée. Si le risque d'explosion des batteries au lithium est bien connu en cas de surchauffe, la particularité ici est que le patient a en outre été ébouillanté par le e-liquide dont le réservoir était très proche de la batterie. Nous montrons ici un défaut de conception de certaines cigarettes électroniques qui devrait être pris en compte par les fabricants et les autorités.

Improvement of facial scar appearance and microcirculation by autologous lipofilling.

BACKGROUND: Autologous lipofilling has become a standard procedure for many indications in plastic surgery. Single-case studies have reported improvements in scars, especially in burn patients, after autologous lipofilling. Despite its widespread use, little is known about the mechanisms responsible for this improvement. It is hypothesized that the mesenchymal stem cells and numerous growth factors contained in the lipoaspirate contribute to the skin and scar remodeling. MATERIAL AND METHODS: Between 2008 and 2012, 35 facial scars (n=35) on 26 patients (n=26) were treated by autologous lipofilling. The preoperative examinations and postoperative follow-up included use of the patient and observer scar assessment scale (POSAS), photo documentation, and laser Doppler spectrometry (O2C) measurements of tissue oxygen saturation, hemoglobin levels, and microcirculation on the second, seventh, and ninetieth postoperative days. RESULTS: The scar quality improved in all cases, leading to a high patient satisfaction rate at the final follow-up examination. The POSAS scores were significantly increased for pain (p=0.0331), color (p=0.0007), stiffness (p=0.0030), irregularity (p=0.0039), pigmentation (p=0.0282), and pliability (p=0.0404). In addition, we observed increased hemoglobin levels in the early postoperative period (second day) and a reduction in the microcirculation, which normalized to the preoperative values after 7-90 days. CONCLUSIONS: We demonstrated that autologous lipofilling represents a valuable technique for the treatment of facial scars. Further prospective observational studies are needed to better understand the mechanisms leading to scar enhancement and to make this procedure more reliable and predictable for patients.

The lipo-facelift: merging the face-lift and liposculpture: eight years experience and a preliminary observational study.

BACKGROUND: Since the introduction of the classic submucosal aponeurotic system (SMAS) face-lift, the surgical approach to improve the changes of an aging face has evolved, and significant technical improvements have been made. However, several problems still have not been solved satisfactorily. These problems include facial lipodystrophy and changes in skin and skin texture. METHODS: The Lipo-Facelift procedure consists of facial liposculpturing performed simultaneously with a biplanar, bivectorial SMAS face-lift procedure. The authors analyzed pre- and postsurgical photographs of 12 patients with a Lipo-Facelift after 3 and 12 months and analyzed their charts for complications. Furthermore, O2C measurement was performed to assess improved microcirculation. The longest follow-up period was 8 years. RESULTS: The Lipo-Facelift demonstrated very satisfying results. Initial swelling and bruising were seen as well as two cases of wound-healing disorders, but no surgical intervention or revision was needed. The findings show lasting improvement of skin quality and a youthful appearance. CONCLUSION: The Lipo-Facelift corrects age-related skin and SMAS changes as well as age-related lipodystrophy, improves skin circulation and skin revitalization, and provides a lasting and natural result. The skin quality resulting from simultaneous lipofilling can be explained by improved angiogenesis due to transferred growth factors in the lipoaspirate. Also, differentiation of progenitor cells to fibroblasts and increased production of collagen contribute to firmer skin. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A rare case of massive carpal osteoblastoma requiring complex reconstructive surgery.

An osteoblastoma is a rare, commonly benign, osteoid-producing neoplasm of the bone with an incidence of 2% of all primary bone tumours. We present a case of a 54-year-old patient with persisting carpal pain and massive swelling of the hand for a period of 4 years. Incision biopsies revealed the histopathological finding of a carpal osteoblastoma. After complete tumour excision, including the carpal and, in parts, metacarpal bones, reconstructive surgery was performed with a free osteocutaneous iliac crest flap to obtain a natural hand contour and the best possible hand function. Follow-up revealed improvement of the hand function in terms of flexion, extension and strength without discomfort or further pain. Thus, ongoing carpal pain should lead to an intensive search with further diagnostic measures such as magnetic resonance imaging (MRI) scan as well as biopsies, if necessary, to obtain the correct diagnosis.

Micro-punch technique for treatment of Fordyce spots: a surgical approach for an unpleasant condition of the male genital.

Fordyce spots are ectopic sebaceous glands, ranging between 2 and 3 mm in diameter. These benign lesions are most frequently located in the oral mucosa and the genital skin. Especially in the male genital region they can cause itching, discomfort during sexual activities and are aesthetically unpleasant. So far, a variety of therapeutic procedures have been reported with varying success and recurrence rates. In the present retrospective study (n = 23 patients between 2003 and 2011), we present our surgical approach by means of the micro-punch technique. Using this effective method, we achieved very satisfactory functional and cosmetic results. There were no signs of recurrence during postoperative observations from 12 up to 84 months (median = 51.3 months).

[Extensive fibromata pendulantia. Hydrosurgery as a therapy option using the Versajet technique]. / Flächenhafte Fibromata pendulantia. Hydrochirurgie als Therapieoption mittels Versajet-Technik.

Fibromata pendulantia often appear as small filiform skin tags with a narrow pedicle in the neck, axilla and groin areas. Hitherto, extensive fibromata pendulantia were resected either surgically (curette, scissors, scalpel) or by laser. The present case study of an adipose patient with disseminated fibromata pendulantia in the axillary region in the setting of pseudoacanthosis nigricans introduces the Versajet hydrosurgery technique as an alternative method. It is able to remove tissue and rinse the wound simultaneously by means of a high-pressure water jet.

A new approach of in vivo musculoskeletal tissue engineering using the epigastric artery as central core vessel of a 3-dimensional construct.

The creation of musculoskeletal tissue represents an alternative for the replacement of soft tissue in reconstructive surgery. However, most of the approaches of creating artificial tissue have their limitations in the size as the maximally obtainable dimension of bioartificial tissue (BAT) is limited due to the lack of supporting vessels within the 3-dimensional construct. The seeded myoblasts require high amounts of perfusion, oxygen, and nutrients to survive. To achieve this, we developed a 3-dimensional scaffold which features the epigastric artery as macroscopic core vessel inside the BAT in a rat model (perfused group, n = 4) and a control group (n = 3) without the epigastric vessels and, therefore, without perfusion. The in vivo monitoring of the transplanted myoblasts was assessed by bioluminescence imaging and showed both the viability of the epigastric artery within the 3-dimensional construct and again that cell survival in vivo is highly depending on the blood supply with the beginning of capillarization within the BAT seven days after transplantation in the perfused group. However, further studies focussing on the matrix improvement will be necessary to create a transplantable BAT with the epigastric artery as anastomosable vessel.

Macrophage migration inhibitory factor is a potential inducer of endothelial progenitor cell mobilization after flap operation.

BACKGROUND: Endothelial progenitor cells (EPCs) promote angiogenesis and play an important role in tissue revascularization and wound healing. Yet, the exact stimuli and mechanisms for the mobilization remain understood poorly. Macrophage migration inhibitory factor (MIF), which is a structurally unique pleiotropic cytokine, has been suggested to play a role in EPC recruitment and thus was a target of this study. METHODS: This study included 20 patients who underwent flap operation. Subjects were divided into 3 groups according to the pattern of flap applied. The number of circulating EPCs and serum levels of MIF or CXCL12 were determined at different time intervals. In vitro chemotaxis experiments using Transwell devices were carried out to test whether MIF promotes the chemotactic migration of EPCs. To underscore functionally the chemotactic potential of MIF toward EPCs in flap patients, the chemotactic effects of serum samples from all groups were also examined in the presence and absence of monoclonal anti-macrophage migration inhibitory factor and anti-CXCL12 antibodies on EPC recruitment using in vitro migration chambers. RESULTS: In flap patients, the number of circulating EPCs and serum levels of MIF but not CXCL12 serum levels were increased markedly compared with preoperative levels at day 1 after operation, especially in the group of free microvascular flaps. Serum levels of CXCL12 in the flap patients were increased only significantly compared with the healthy control group. An analysis between EPCs and MIF revealed a significant correlation, whereas no correlation was observed for CXCL12. MIF exerted a dose-dependent, prochemotactic effect on isolated human EPCs, and serum samples from all flap patients promoted EPC migration. Importantly, this effect was blocked partially by anti-macrophage migration inhibitory factor and to a weaker extent by anti-CXCL12 antibodies. CONCLUSION: We conclude that MIF plays an important role in the mobilization of EPCs, which is dependent on the degree of ischemia. Enhancement by MIF of chemotactic EPCs migration in vitro underpins its proposed in vivo function.

[Liposuction]. / Liposuktion.

Liposuction is one of the most commonly performed procedures in aesthetic surgery. The primary aim is body contouring and not weight reduction. The vast amount of available methods for suctioning subcutaneous fat allows an optimal individual treatment plan, keeping in mind the correct indications. Although liposuction is often offered as a minor and harmless surgery, it is a complex procedure. A thorough training of the surgeon and in-depth knowledge about possible complications is essential. In addition to aesthetic indications liposuction is also a valuable tool in reconstructive surgery. For optimal patient selection the skin elasticity has to be considered during the preoperative assessment. Besides pure volume reduction through liposuction, the regenerative possibilities of adipose tissue are of great interest for basic research and clinical applications. Lipofilling or autologous fat transfer is used for a wide variety of aesthetic and reconstructive procedures. Of special interest is the regenerative and reconstructive potential of adipose-derived stem cells (ADSC).

A four-muscle-flap for thoracomyoplasty in patients with sacrificed thoracodorsal vessels.

UNLABELLED: Defects after prior posterolateral thoracotomy and with concomitant bronchiopleural fistula remain a challenge for the plastic surgeon. In most of the cases, the thoracodorsal artery division after posterolateral thoracotomy impairs the vascularisation supply of the latissimus dorsi, resulting in the loss of this option for closure of the pleural cavity. Therefore, the adequate filling of residual empyema space and/or surgical closure of the bronchial stump insufficiency needs additional tissue to overcome this situation. We present an alternative approach using a four-muscle-flap technique including the infraspinatus, the subscapularis and the teres major and minor muscle group, all pedicled from the subscapular artery as a part of a modified thoracomyoplasty technique for closing the residual empyema space and bronchial stump insufficiency. METHODS: Between 2002 and 2008, we performed the four-muscle-flap on seven patients (mean age 68±7.9 years) with residual empyema space. Three cases were combined with a bronchopleural fistula. All patients received a two-stage procedure. First, the thoracic surgeons performed an open-window thoracostomy. This procedure was followed by the definitive surgical treatment after 3-6 months. In cases with an additional bronchial insufficiency, the stump was covered in with a subscapularis muscle. The infraspinatus and the teres muscle group were used to fill the pleural cavity, in combination with the thoracoplasty. RESULTS: In this series, no mortality connected to the procedure was noted. The mean postoperative stay in the intensive care unit (ICU) was 3±2.9 days and the patients were discharged from the hospital after 15±7.6 days. Minor postoperative complications occurred in two cases. Shoulder abduction in all patients was possible up to 90° and has decreased around 15±10° postoperatively. CONCLUSIONS: The division of the thoracodorsal pedicle and the consecutive loss of the latissimus as a reconstructive option remain challenging. The lower shoulder girdle muscles (infraspinatus, subscapularis, teres minor and major) are an adequate alternative for filling residual empyema spaces. The constraint in shoulder movement is minor and acceptable in such situations.

[Alloplastic cancellous bone replacement and fibrin glue in hand surgery]. / Alloplastischer Spongiosaersatz mit Fibrinkleber in der Handchirurgie.

INTRODUCTION: Alloplastic replacement of cancellous bone is being increasingly used in the clinical setting. The use in hand surgery, however, is only sparsely documented. MATERIALS AND METHODS: We report about the use of micro- and macroporous biphasic calicium phosphate granulate (Tricos (®)) in combination with fibrin sealant (Tissucol (®)) in six patients undergoing surgery of the hand involving cancellous bone deficits. The indications ranged from carpal stabilisation to DIP athrodesis. Follow-up time was up to 15 months. RESULTS: Because cancellous bone harvesting could be avoided, morbidity and the extent of surgery could be reduced in all patients. Healing was uneventful and the clinical course as documented by X-ray controls, toleration of physiotherapeutic exercises and stability was analogous to that of conventional surgery involving cancellous bone grafting. CONCLUSION: These first results indicate that alloplastic replacement of spongiosa grafts, especially by micro- and macroporous biphasic calcium phosphate granulate can possibly be successfully used in surgery of the hand. The extent of bony remodelling still needs to be determined by further examination.

[Current perspective and limitations of autologous fat transplantation--"consensus meeting" of the German Society of Plastic, Reconstructive and Aesthetic Surgeons at Hannover; September 2009]. / Möglichkeiten und Grenzen der autologen Fetttransplantation--"Consensus Meeting" der DGPRAC in Hannover, September 2009.

One hundred years after the first description of autologous fat transplantation, this technique is receiving renewed attention. Initially, critically reviewed by plastic surgery societies, particularly those in the United States, the transfer of autologous fat was recently addressed at the September 2009 annual meeting of the German Society of Plastic Reconstructive and Aesthetic Surgeons in Hannover. In this consensus meeting, the panel reviewed both the current status of autologous fat transfer as well as established data concerning this evolving practice. In Germany, autologous fat transplantation is regulated by the Law on Tissue Transfer and Processing (Gewebegesetz). In an effort to facilitate future comparisons it is mandatory to describe harvesting, processing and reinjection techniques in detail. The consensus panel concluded that fat should be harvested using low vacuum settings and then transplanted in thin layers (Evidence V). Quantification of transplanted fat can best be performed by MRI (Evidence level III). Limited clinical studies are available with only some reaching a level of evidence II. At present, risk associated with autologous fat transplantation is considered to be minor. Tumor induction by autologous fat grafting is not proven. New techniques like stem cell enriched fat grafts may offer new promise for the Plastic and Reconstructive Surgeon.